Demographics Form ← BackThank you for your response. ✨ Thank you for your interested in my services. Please complete the following form with the intended client’s information. If you are interested in couples therapy, please complete a form for both individuals. This information will be emailed directly to Jenn Teutscher. I look forward to working with you! Legal First and Last Name(required) Warning Todays Date Warning Date of Birth(required) Warning Address(required) Warning Email(required) Warning May I contact you via email?(required) Yes No Warning May I email you forms through Adobe Acrobat Sign?(required) Yes No Warning Phone Number(required) Warning May I contact you on this number?(required) Yes No Warning Insurance Provider/Plan Name Warning Insurance Patient ID Warning How did you hear about me? Warning If client is MINOR, person responsible/guardian (please identify NAME, RELATION, AND PHONE NUMBER). Warning Emergency Contact Information Emergency Contact Name(required) Warning Relationship to Emergency Contact(required) Warning Emergency Contact Phone Number(required) Warning Identity Information Ethnicity/National Origin Warning Current Religious Denomination/Affiliation Warning Religious/Spiritual Involvement None Some/Irregular Active Warning Gender Identity Female Male Transgender Non-binary Gender Neutral Pangender Genderqueer Warning Sexual Orientation Asexual (lack of sexual interest in either men or women) Bi-Sexual (sexual interest in both men and women) Gay/Lesbian (sexual interest in a member of the same sex) Heterosexual (sexual interest in a member of the opposite sex) Questioning (still exploring or unsure of sexual orientation) Warning Other related way you identify yourself and consider important Warning Warning. SendSubmitting form Δ
Jenn Teutscher, LMFT 